P. 1
09 Acute Med Abd

09 Acute Med Abd

|Views: 28|Likes:
Published by Daniela

More info:

Published by: Daniela on Jan 27, 2011
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PPT, PDF, TXT or read online from Scribd
See more
See less

11/23/2013

pdf

text

original

Acute medical abdomen

Features: ‡ severe abdominal pain, with brutal onset ‡ local and general signs ‡ EMERGENCY: - establish immediate diagnosis - take immediate action - prevent fatal event

Two forms: - the medical acute abdomen - the surgical acute abdomen It is necessary for the practitioner to know the etiopathogenic classification in order to formulate a correct diagnosis an soon as possible and to establish the appropriate therapeutic attitude.

DIAGNOSIS

‡ History ‡ Physical examination ‡ Limited lab tests

IS THE PAIN ACUTE OR CHRONIC?
Did the pain recently start or has it occured for weeks,months or years? ‡ Chronic: mild chronic discomfort localized to one area (perforated duodenal ulcer or perforated diverticulum) ‡ Acute: recurrent attacks of severe colic (gallstones, kidney stones, mild intestinal obstruction caused by a benign tumor, such as a carcinoid).

WAS THE ONSET SUDDEN?
‡Pain that is sudden in onset, severe or explosive, progressive, continuous, and lasts more than 6 hours generally indicates surgical etiology ‡Pain that is gradual in onset, mild to moderate in intensity, intermittent, recurrent, or resolves partially or completely in less than 6 hours favors a nonsurgical diagnosis.

HOW WAS THE ONSET? Persistent pain that awakens the patient or begins during relative inactivity surgical solution

Pain that occurs during Strenuous activity or after eating

nonsurgical diagnosis

WHERE IS THE PAIN?
‡ Epigastric pain: ‡ stomach, duodenum, intestine, gallbladder, or pancreas ‡ Appendicitis: usually it is the initial site before the pain shifts to the right lower quadrant. ‡ Pain in periumbilical area arising from midgut derivatives: ‡ jejunum, ileum, proximal third of the colon, and appendix. ‡ Pain in the hypogastrium arising from the embryonic hindgut ‡ distal two-thirds of the colon ‡ internal reproductive organs (ovaries, fallopian tubes, uterus, seminal vesicles, and prostate) ‡ the urinary bladder

Location of Abdominal Pain
‡Four quadrants: oRight Upper Quadrant oRight Lower Quadrant oLeft Upper Quadrant oLeft Lower Quadrant ‡Three central areas: oEpigastric oPeriumbilical oSuprapubic

Digestive system

DOES THE PAIN RADIATE?

‡ Gallbladder pain

beneath the right scapula the left shoulder

‡ Left diaphragmatic irritation ‡ Renal pain

the region of pubis or vagina

‡ Ruptured aortic aneurysm: severe pain beginning in the
midback rapidly spreading to the abdomen

Radiation of Abdominal Pain
‡Perforated Ulcer ‡Biliary Colic ‡Renal Colic ‡Dysmenorrhea/Labor ‡Renal Colic (Groin)

HOW IS THE PAIN DESCRIBED?
‡ Severe, knifelike pain: ‡ ‡ ‡ ‡ ‡ ‡
± associated with shock EMERGENCY! Burning pains: ± Peptic ulcers Acute waves of sharp constricting pain (³take the breath away´): ± Renal or biliary colic Tearing pain: ± Dissecting aneurysm Ache: ± Appendicitis Dull ache in the region of the kidney: ± Pyelonephritis Colicky pain that becomes steady: ± Appendicitis, strangulating intestinal obstruction, or a very serious vascular accident.

WHAT GIVES RELIEF?

‡ Antacids:
± Peptic ulcer

‡ During the acute attack:
± Walking the floor biliary colic ± The patient lies as quietly as possible peritonitis

ARE OTHER SYMPTOMS ASSOCIATED WITH THE PAIN?
‡ Vomiting:
± If it precedes pain and esp. if it is followed shortly by diarrhea gastroenteritis ± 3 mechanisms: ‡ Severe irritation of local peritoneum or mesentery ‡ Obstruction of a muscular tube (bile duct, intestine, ureter) ‡ Absorbed toxin or drug stimulation of CNS centers controlling the vomiting reflex ± Severe vomiting that precedes an intense epigastric, left chest, or shoulder pain emetic perforation of intra-abdominal esophagus. ± 1 or 2 times/hour after the onset of pain appendicitis ± Acute intestinal obstruction: the lower the site of obstruction, the more delayed is the vomiting

‡ Shock, pallor, sweating, fainting

ARE OTHER SYMPTOMS ASSOCIATED WITH THE PAIN?

‡ nausea ‡ anorexia ‡ fever ‡ chills ‡ constipation ‡ diarrhea. In surgical conditions: pain may be followed by nausea, vomiting, and anorexia. In nonsurgical conditions nausea, vomiting, and anorexia typically precede pain.

ARE OTHER SYMPTOMS ASSOCIATED WITH THE PAIN?
‡ Anorexia is uncommon in: ‡ athletes ‡ especially in obese individuals ‡ Fever is a common finding ‡ This combination suggests infection in the urinary tract, respiratory system, etc.

ARE OTHER SYMPTOMS ASSOCIATED WITH THE PAIN?
‡ Constipation may accompany any abdominal condition that causes an illness ‡Obstipation-nonpassage of both stool and however, always suggests a surgical problem gas--

‡ Diarrhea, especially with cramps: ‡ gastroenteritis ‡ other non-surgical conditions (inflammatory bowel disease).

WHAT AGGRAVATES THE PAIN?
‡ Coughing, ‡ sneezing, ‡ rapid movements, ‡ walking, especially down stairs

peritoneal irritation

‡ Musculoskeletal pain is often relieved by changing position. ‡ A bowel movement often eases the gastroenteritis, but the pain may promptly recur. pain of

HISTORY OF PRECEDING SYMPTOMS
‡ Previous symptoms and history of:
± ± ± ± ± ± ± ± ± ± ± ± Ulcer disease Gallstone colic Diverticular disease Esophageal reflux Diarrhea Constipation Jaundice Melena Hematuria Hematemesis Weight loss Mucus or blood in stool

Can help establish the diagnosis

DRUG HISTORY
‡ Details concerning drugs, both therapeutic and addictive:
± K tablets: highly irritating to the intestin perforation and peritonitis ± Prednisone or immunosuppresive increase the chance of perforation of some portion of the GI tract ± Anticoagulants bleedings.

FAMILY HISTORY OF CERTAIN DISEASES
‡ Pain ‡ Vomiting ‡ Diarrhea

In other family members

gastroenteritis

GENERAL PHYSICAL EXAMINATION

‡ Must not be neglected ‡ BP, pulse, state of consciousness, degree of shock ‡ PERISTALSIS:
± Active peristalsis of normal pitch nonsurgical disease (gastroenteritis) ± High-pitched peristalsis or borborygmi in rushes intestinal obstruction ± Severe pain and absolutely silent abdomen IMMEDIATE EXPLORATION!

GENERAL PHYSICAL EXAMINATION

‡ ‡ ‡ ‡ ‡

Tenderness Rebound tenderness Degree of distention Palpable masses Operative scars adhesions and intestinal obstructions ‡ Orifices external hernias

Tip to remember
‡ Pain arising in a hollow, tubular structure, such as the ureter, intestine, biliary tract, or fallopian tubes, may be continuous or intermittent ‡ The severity of such pain is inversely proportional to the diameter of the tubular structure involved

GENERAL PHYSICAL EXAMINATION

‡ Rectal and pelvic examinations ‡ Jaundice or evidence of bleeding in subcutaneous
tissues
± Retroperitoneal bleeding from ‡ hemorrhagic pancreatitis ‡ Dissecting bluish discoloration ‡ Frank ecchymoses of the costovertebral angles (Grey Turner¶s sign) or around the umbilicus (Cullen¶s sign)

Murphy¶s Sign

Technique A.Maneuver: Deep subcostal palpation of right upper quadrant on inspiration B.Positive: Worsened pain Suggests Acute Cholecystitis

Carnett's Sign
Interpretation of abdominal muscle wall pain 1. Intra-abdominal pain source = Negative Carnett's Sign (abdominal pain decreases with tensing abdomen) 2. Abdominal Muscle Wall Pain = Positive Carnett's Sign (pain increases or remains unchanged) Technique A. B. Patient lies supine Patient tenses abdominal wall by 1. 2. Lifting head off table Lifting shoulder off table

Laboratory studies

Confirmation only CBC, UA, Blood chemistries Serum and urinary amylase Use lab only as needed, not as a ³Shotgun´

Radiographic and Endoscopic studies
Confirmation only Start with simple and inexpensive studies - x-rays - IVU - US - CT

Common Causes of Acute Abdominal Pain
*Condition requires urgent surgery

Gastrointestinal Tract
Appendicitis, acute* Meckel's diverticulitis* Perforated bowel* Perforated peptic ulcer* Small and large bowel obstruction* Strangulated hernia* Diverticulitis Gastritis Gastroenteritis Inflammatory bowel disease Mesenteric lymphadenitis

Liver, Spleen, and Biliary Tract
Cholangitis, acute* Cholecystitis, acute* Hepatic abscess* Ruptured hepatic tumor* Ruptured spleen* Biliary colic Hepatitis, acute Splenic infarct

Peritoneum
Intra-abdominal abscess* Primary peritonitis Tuberculous peritonitis

Pancreas
Acute pancreatitis

Urinary Tract
Cystitis, acute Pyelonephritis, acute Renal infarct Ureteral or renal colic

Female Reproductive System
Ruptured ectopic pregnancy* Ruptured ovarian follicular cyst* Twisted ovarian tumor* Dysmenorrhea Endometriosis Salpingitis, acute

Vascular System
Ischemia, acute* Mesenteric thrombosis* Ruptured arterial aneurysm*

Retroperitoneum
Retroperitoneal hemorrhage

Generalized Abdominal Pain Causes
‡ ‡ ‡ ‡ ‡ ‡ ‡
Peritonitis Pancreatitis Leukemia Sickle Cell Crisis Early Appendicitis Mesenteric Adenitis Mesenteric Thrombosis

‡ Gastroenteritis ‡ Abdominal Aortic ‡ ‡ ‡ ‡
aneurysm Splenic artery aneurysm Mesenteric Artery aneurysm Colitis Intestinal obstruction

Left Lower Quadrant Pain Causes ‡ Appendicitis ‡ Intestinal obstruction ‡ Constipation ‡ Diverticulitis ‡ Leaking aneurysm ‡ Abdominal wall hematoma ‡ Ovarian cyst or torsion ‡ Ureteral calculus (Nephrolitiasis) ‡ Renal pain ‡ Seminal vesiculitis ‡ Psoas abscess

Left Upper Quadrant Abdominal Pain Causes
Gastritis Pancreatitis Splenic enlargement, rupture, infarction, aneurysm Renal pain Herpes Zoster Myocardial Ischemia Pneumonia Empyema

Right Lower Quadrant Pain Causes
Appendicitis Intestinal obstruction Regional enteritis Diverticulitis Cholecystitis Perforated Ulcer Leaking aneurysm Abdominal wall hematoma Ovarian cyst or torsion Ureteral calculus (Nephrolithiasis) Renal pain Seminal vesiculitis Psoas abscess

Right Upper Quadrant Pain Causes
Gall Bladder or Billiary Tract Disease Hepatitis Hepatic abscess Hepatomegaly due to Congestive heart failure Peptic Ulcer Pancreatitis Retrocecal Appendicitis Renal pain Herpes Zoster Myocardial Ischemia Pericarditis Pneumonia Empyema

Extraperitoneal Abdominal Pain Causes

I.Cardiopulmonary Causes A.Cardiopulmonary Causes B.Pneumonia C.Empyema D.Myocardial Infarction E.Active Rheumatic Heart Disease F.Aortic Dissection II.Hematologic Causes A.Leukemia B.Sickle Cell Crisis

III. Neurologic Causes A.Spinal cord tunor B.Spinal Osteomyelitis C.Tabes dorsalis D.Herpes Zoster E.Abdominal Epilepsy F.Abdominal Migraine IV. Genitourinary and Renal Causes A.Pyelonephritis B.Perinephric abscess C.Nephrolithiasis or other Ureteral obstruction D.Prostatitis E.Seminal vesiculitis F.Epididymitis

V. Metabolic Causes A.Uremia B.Diabetic acidosis C.Porphyria D.Addison's Disease in crisis VI. Toxins A.Bacterial Infection B.Insect Bites C.Snake Bite Venoms D.Spider Bite Venoms (e.g. Black Widow Spider Bite) E.Drugs F.Lead poisoning

Things to Remember
‡Consider inguinal/rectal examination in males ‡Consider pelvic/rectal examination in females ‡Inflammatory bowel disease can mimic acute apendicitis ‡Herpes zoster ± confusing pain if located in right lower quadrant ‡Pneumonia-diffuse radiated abdominal pain, no tenderness ‡ Acute MI ± diffuse abdominal pain ‡Drug addicts ± severe colicky pain ‡ Spinal/CNS disease ± radiculitis, reffered pain ‡ Psychogenic somatoform disorders

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->